Positioning and sequencing of advanced therapies in inflammatory bowel disease: A guide for clinical practice

Table 2 Basic principles in positioning and sequencing advanced therapies in inflammatory bowel disease

Basic principles
Start any effective drug as early as possible
Be aware: The first drug chosen will likely be the most effective for controlling IBD, particularly in Crohn's disease
Avoid repeated courses of steroids before initiating advanced therapies. The need for steroids should alert clinicians to the likely necessity of starting steroid-sparing therapeutic strategies
Assess factors that may influence the pharmacokinetics of biologics, such as hypoalbuminemia, high inflammatory load, extensive gastrointestinal involvement, and others
Consider factors that may impact on the safety of different therapies
Use the best available evidence to guide the selection of initial therapy and, when appropriate, the subsequent sequencing of treatments
Consider the potential need for treatment escalation strategies in the context of more severe disease
Always think ahead: Which agent could also be effective as a second-line treatment?
Consider the patient as a whole: Take into account factors such as age, frailty, underlying comorbidities, extraintestinal manifestations, and others
The selection of advanced targeted therapy must take into account costs, access to treatment, and any barriers to receiving therapy

IBD: Inflammatory bowel disease.